Psychosocial stressors may exacerbate observed associations between environmental toxicants and adverse birth outcomes. However, studies have primarily focused on well-known compounds rather than a broader range of chemicals of concern. Pregnant women in this analysis had a prenatal urine sample analyzed for 113 well-studied and understudied chemical analytes, and at least one measure of psychosocial stress (N = 1566). We measured analytes from 10 chemical classes, including fungicides/herbicides, insecticides, halogenated phenols, organophosphorus flame retardants, benzophenones, bisphenols, parabens, antimicrobials, phthalates/alternative plasticizers, and polycyclic aromatic hydrocarbons. Principal component analysis was used to identify clusters of exposure patterns. Generalized Estimating Equation models assessed associations between principal components (PCs) and molar sums of each chemical class with birthweight z-scores and gestational age at birth, stratified by individual stressors (i.e., categorical adverse childhood experiences [ACEs; 0, 1-2, and 3-5]; binary prenatal perceived stress, depression, and anxiety). The PC reflecting higher exposure to all analytes (PC1) was negatively associated with birthweight z-scores only among those who experienced 3-5 ACEs compared with those with no ACEs (βPC1 = -0.08, 95 % confidence interval [CI] = -0.11, -0.05 for 3-5 ACEs; βPC1 = -0.01, 95 % CI = -0.05, 0.04 for 0 A CEs). Most phthalate molar sums were inversely associated with gestational age only among those with anxiety during pregnancy (e.g., βDINP = -0.29, 95 % CI = -0.41, -0.18 for anxiety-yes; βDINP = 0.23, 95 % CI = 0.01, 0.46 for anxiety-no). Findings suggest that certain psychosocial stressors modify associations between understudied chemicals and birth outcomes.

To understand staff perspectives on racism experienced by both parents and staff members in the neonatal intensive care unit (NICU). Open-ended surveys and semi-structured interviews were conducted with staff at an urban level IV NICU from 2021 to 2022. Themes were generated and refined using thematic analysis. The main outcome constituted participants’ experiences of structural racism. 72 multi-disciplinary and racially and ethnically diverse participants completed the survey and 10 participants were also interviewed. Five major themes were identified: (1) a wide range of denial and recognition of racism existed, (2) workplace culture and relationships both protected against and facilitated racism, (3) staff experienced a lack of workforce diversity and minority tax, and witnessed (4) biased communication and language barriers, and (5) disparate resource allocation. Similar to other healthcare worker and caregiver reports, NICU staff members also experience and witness interpersonal, institutional, and structural forms of racism.

OBJECTIVE:To examine pediatric residents' perspectives and education on neonatal health inequities, thereby identifying training needs and opportunities to improve health inequities for newborns. METHODS:We performed an Institutional Review Board (IRB)-approved multi-institutional, qualitative study. Over 18 months, we conducted 10 focus groups across Bay Area institutions. We developed focus group guides using literature review, expert consensus, and feedback from health equity experts. Focus groups were audio-recorded and transcribed verbatim. We used thematic analysis to code transcripts and develop themes until reaching thematic sufficiency, employing reflexivity and member checking. RESULTS:Five key themes emerged across 44 pediatric resident focus group participants. 1) Residents spotlight how neonatal inequities influence patient outcomes, finding difficulties in addressing them in real-time due to systems-level barriers and limited action-oriented knowledge. 2) Residents express a high level of moral distress and cognitive dissonance over the perceived inability to fully address inequities in the clinical setting, seeking a safe space to communicate these emotions. 3) Residents desire protected time for longitudinal reflection and action-oriented education about inequities throughout residency. 4) Residents emphasize the importance of faculty role modeling their knowledge and approach to addressing inequities, highlighting a need for ongoing faculty development. 5) Collaboration with multidisciplinary care team members, families, and community partners is central to a well-rounded curriculum. CONCLUSIONS:These findings underscore the need to enhance action-based health equity education in pediatric training. Addressing these identified themes can improve resident preparedness to mitigate health disparities in neonatal care, fostering equitable outcomes for newborns.

OBJECTIVE:To identify Black preterm infant caregiver experiences and institutional priorities regarding screening and addressing social drivers of health (SDH). STUDY DESIGN:In the Centering Black Preterm Infant Caregiver Priorities study, Black female researchers conducted semistructured interviews in 2024 with Black caregivers of preterm infants born in the San Francisco Bay Area of California. Transcripts were coded using a book generated from an interview guide, and the resulting data were analyzed using thematic analysis. Themes were generated and refined through discussion. RESULTS:Twenty sociodemographically diverse caregivers participated. Five themes were identified: (1) financial insecurity and inadequate access to resources for everyday social needs contribute negatively to caregiver and child health and well-being; (2) a trusted provider who takes a personal approach to screening and addressing SDH is needed in medical settings; (3) inequitably distributed, fragmented, and disorganized medical and social support systems in the transition to home period are burdensome and a source of stress; (4) community-based organizations centering Black families holistically address SDH and promote social well-being and connectedness; and (5) state and federal legislation, policies, and programs are critical opportunities to address SDH. CONCLUSIONS:SDH are a significant source of stress for caregivers after preterm birth, and there are opportunities across state and federal legislative policies, community-based organizations, medical systems, and connections across the systems to address them.

Health is a fundamental human right and families deserve health equity, a state where all children have the opportunity to reach their full health potential. Black families and children are disproportionately burdened with racial inequities in morbidity and mortality. Although evidence supports racially concordant care and wraparound pediatric primary services to address racial inequities, there remains a significant gap in developing and evaluating such clinics. Here, we introduce an innovative approach to pediatric primary care for Black children in Oakland, California, the Black Love Opportunity and Outcome Improvement in Medicine (BLOOM) clinic. Responsive to contemporary understanding of the racialized harms experienced by Black families, the BLOOM clinic combines racial concordance and culturally responsive care with extensive psychosocial support and resources to address social drivers of health for Black families. In this article, we describe the impetus, vision, mission, and objectives, structure and components, key outcomes, future research evaluation, challenges, and lessons learned from developing and implementing the BLOOM clinic. Key outcomes described include obtaining funding and institutional commitment, developing community partnerships, launching the clinic, implementing and providing services, and reflecting on the initial reception by staff and parents. The primary purpose of this article is to share the process and strategy of building this innovative clinic with others who may be interested in learning from the process in their own paths to advance racial health equity for Black children.

OBJECTIVES:To evaluate disparities in 1-year mortality in infants with congenital diaphragmatic hernia (CDH) by maternal race/ethnicity in a US population-based dataset, and to quantify mediation effects of socioeconomic status (SES) and maternal and neonatal medical factors. STUDY DESIGN:We identified infants with CDH from the US Natality Database (2014-2019) that links birth and death certificates to 1-year of age. Primary outcome was 1-year mortality. Primary predictor was maternal race/ethnicity. Candidate mediators (SES [defined by maternal education level and public insurance status] and neonatal and maternal factors) were assessed using structural equation modeling. RESULTS:Among 2589 infants with CDH, 1-year mortality was 28.4% (n = 734). Infant mortality differed by maternal race/ethnicity: Non-Hispanic White 25.5%, Black 39.1%, Hispanic 31.2%. Mortality differences persisted in multivariate analysis. Mediation analyses showed that SES accounted for 54.1% (20.4-68.6%) of the disparity between infants of Non-Hispanic White and Hispanic mothers. In contrast, SES accounted for only 17.1% (3.6-37.4%) of the disparity between infants of Non-Hispanic White and Black mothers, while the unmeasured remaining effect of race/ethnicity contributed 75.9% (49.5-91.1%). CONCLUSIONS:In CDH, SES accounts for a large proportion of the mortality disparity for infants of Hispanic mothers while the remaining effect of race, aside from SES and neonatal factors, accounts for a large proportion of the mortality disparity for infants of Black mothers. The remaining effect of maternal race may be due to unmeasured aspects of SES, such as social determinants of health, and structural and systemic racism and bias.

OBJECTIVES:Few studies have analyzed potential inequities in both pediatric patient safety events (PSEs) and adverse events (AEs) - PSEs leading to harm - nor in PSEs by event type. We sought to examine potential inequities in rates of pediatric PSEs overall, by severity, and by category based on race and ethnicity, insurance payor, and language as measured using voluntary incident reports (IRs). METHODS:We conducted a retrospective cohort study of pediatric hospitalizations between January 19, 2012 through December 31, 2019 at a US urban, tertiary care children's hospital. Analyzing 85 458 hospitalizations, we compared PSEs overall, by severity, and by event category by race and ethnicity, insurance payor, and language using incident rate ratios (IRRs). RESULTS:In models controlling for covariates, we found that hospitalizations of Latinx (IRR 1.17, 95% confidence interval [CI] 1.07-1.29), non-Latinx Black/African American (IRR 1.17, 95% CI 1.01-1.34), publicly insured (IRR 1.10, 95% CI 1.02-1.20), and nonprivately/nonpublicly insured (IRR 1.12, 95% CI 1.02-1.23) children had higher rates of PSEs compared with reference groups, but the association between language and PSEs was not significant. There were similar patterns among AEs, although only the association between hospitalizations of Latinx patients and AEs was significant. Medication, fluid, or blood and lines or tubes PSEs drove many inequities. CONCLUSIONS:We found inequities in PSEs as recorded by IRs, suggesting differences in care related to race, ethnicity, and payor. Limitations include analysis of a single center, that event categories are unique to the institution analyzed, and the voluntary nature of IRs.

To understand local mechanisms of racial inequities and generate recommendations from community members regarding how to promote racial equity in the Neonatal Intensive Care Unit (NICU). In an urban tertiary care NICU, 4 semi-structured in-person focus groups with follow-up audio diaries were conducted with NICU parents and staff from 2022–2023 with support from interpreters, a psychologist, and a family advocate. Researchers coded transcripts independently and thematic analysis was utilized to generate and refine themes. 16 racially diverse and multidisciplinary staff and parents participated, and six themes emerged from the data. Mechanisms of racial inequities included power dynamics, interpersonal and institutional dehumanization, and societal inequities. Recommendations included redistributing power, transforming space and staff to promote humanism, and mitigating harm through peer support and resource allocation. Focus groups are a promising strategy to identify interventions to address racial inequities. Future research should focus on intervention implementation and evaluation.

Impact In alignment with previous literature, NICU parents reported experiencing racism and NICU staff reported witnessing racism in the NICU. Our study also uniquely describes personal experiences with racism by staff in the NICU. NICU staff reported witnessing and experiencing racism more often than parents reported. Black staff reported witnessing and experiencing more racism than white staff. Differences in reporting is likely influenced by variations in lived experience, social identities, psychological safety, and levels of awareness. Future studies are necessary to prevent and accurately measure racism in the NICU.

Objective To describe changes over time in resuscitation, survival, and morbidity of extremely preterm infants in California. Study design This population-based, retrospective cohort study includes infants born ≤28 weeks. Linked birth certificates and hospital discharge records were used to evaluate active resuscitation, survival, and morbidity across two epochs (2011–2014, 2015–2019). Results Of liveborn infants, 0.6% were born ≤28 weeks. Active resuscitation increased from 16.9% of 22-week infants to 98.1% of 25-week infants and increased over time in 22-, 23-, and 25-week infants ( p -value ≤ 0.01). Among resuscitated infants, survival to discharge increased from 33.2% at 22 weeks to 96.1% at 28 weeks. Survival without major morbidity improved over time for 28-week infants ( p -value < 0.01). Conclusion Among infants ≤28 weeks, resuscitation and survival increased with gestational age and morbidity decreased. Over time, active resuscitation of periviable infants and morbidity-free survival of 28-week infants increased. These trends may inform counseling around extremely preterm birth.

ImportanceSudden infant death syndrome (SIDS) is a major cause of infant death in the US. Previous research suggests that inborn errors of metabolism may contribute to SIDS, yet the relationship between SIDS and biomarkers of metabolism remains unclear.ObjectiveTo evaluate and model the association between routinely measured newborn metabolic markers and SIDS in combination with established risk factors for SIDS.Design, Setting, and ParticipantsThis was a case-control study nested within a retrospective cohort using data from the California Office of Statewide Health Planning and Development and the California Department of Public Health. The study population included infants born in California between 2005 and 2011 with full metabolic data collected as part of routine newborn screening (NBS). SIDS cases were matched to controls at a ratio of 1:4 by gestational age and birth weight z score. Matched data were split into training (2/3) and testing (1/3) subsets. Data were analyzed from January 2005 to December 2011.ExposuresMetabolites measured by NBS and established risk factors for SIDS.Main Outcomes and MeasuresThe primary outcome was SIDS. Logistic regression was used to evaluate the association between metabolic markers combined with known risk factors and SIDS.ResultsOf 2 276 578 eligible infants, 354 SIDS (0.016%) cases (mean [SD] gestational age, 38.3 [2.3] weeks; 220 male [62.1%]) and 1416 controls (mean [SD] gestational age, 38.3 [2.3] weeks; 723 male [51.1%]) were identified. In multivariable analysis, 14 NBS metabolites were significantly associated with SIDS in a univariate analysis: 17-hydroxyprogesterone, alanine, methionine, proline, tyrosine, valine, free carnitine, acetyl-L-carnitine, malonyl carnitine, glutarylcarnitine, lauroyl-L-carnitine, dodecenoylcarnitine, 3-hydroxytetradecanoylcarnitine, and linoleoylcarnitine. The area under the receiver operating characteristic curve for a 14-marker SIDS model, which included 8 metabolites, was 0.75 (95% CI, 0.72-0.79) in the training set and was 0.70 (95% CI, 0.65-0.76) in the test set. Of 32 infants in the test set with model-predicted probability greater than 0.5, a total of 20 (62.5%) had SIDS. These infants had 14.4 times the odds (95% CI, 6.0-34.5) of having SIDS compared with those with a model-predicted probability less than 0.1.Conclusions and RelevanceResults from this case-control study showed an association between aberrant metabolic analytes at birth and SIDS. These findings suggest that we may be able to identify infants at increased risk for SIDS soon after birth, which could inform further mechanistic research and clinical efforts focused on monitoring and prevention.

Few studies have investigated parent's experiences with racism in the neonatal intensive care unit (NICU). Our objective was to explore how parents perceive their interactions with NICU staff and if/how racism in the NICU was experienced. Parents of infants receiving care in an urban NICU completed fixed choice surveys regarding their experiences and demographics, with 6 open-ended questions to elaborate on their fixed-choice responses. Using a constant comparative method informed by Constructivist Grounded Theory, we identified 3 main themes from the comments provided by 97 respondents: Care and harm coexisting, racism often manifesting as neglectful care, and the power differential is most impactful during times of parent advocacy. Parents spoke positively regarding their experiences and also reported disparate treatment attributed to their racial/ethnic identity. Racism was experienced by inappropriate comments and apathy toward parent requests, occurring during intimate interactions between staff and parents. Descriptions of parental advocacy efforts highlighted the lack of power they held in relation to the NICU staff. We recommend strengthening the focus on equity and mitigating power imbalances in the NICU.

Importance:Preterm birth (PTB) (gestational age <37 weeks) is a major cause of infant mortality and morbidity in the US and is marked by racial and ethnic and socioeconomic inequities. Further research is needed to elucidate the association of risk and protective factors with trends in PTB rates and with related inequities. Objective:To describe the association of PTB rates with inequities as well as related risk and protective factors over the past decade in a US population-based cohort. Design, Setting, and Participants:This retrospective cohort study of singleton live births in California from January 1, 2011, to December 31, 2022, was conducted using vital statistics records and hospital records. The cohort included births with a gestational age of 22 to 44 weeks. Main Outcomes and Measures:Preterm birth rates by racial and ethnic group and by public and nonpublic insurance (considered as a proxy for socioeconomic status) were studied across years. Log-linear regression (relative risks with 95% CIs) was used to evaluate risk and protective factors within groups. Associations of PTB rates with risk and protective factors were assessed. Results:This study included 5 431 018 singleton live births to individuals who identified as American Indian or Alaska Native (0.3%), Asian (14.2%), Black (4.9%), Hispanic (47.8%), or White (27.0%). A total of 43.1% of births were to individuals with public health insurance. From 2011 to 2022, the overall PTB rate increased from 6.8% to 7.5% (change [SE], 10.6% [0.6%]; z score of 18.5; P < .001). Differences in PTB rates and associated changes were observed for racial and ethnic groups and insurance groups. For example, 2022 PTB rates ranged from 5.8% among White individuals with nonpublic insurance to 11.3% among Black individuals with public health insurance. From 2011 to 2022, PTB rates decreased from 9.1% to 8.8% (change [SE], -3.5% [4.2]; z score of -0.8; P = .42) among Black individuals with nonpublic insurance, whereas they increased from 6.4% to 9.5% (change [SE], 49.8% [16.0%]; z score of 3.1; P = .002) among American Indian or Alaska Native individuals with nonpublic insurance. Increases in some risk factors (eg, preexisting diabetes, sexually transmitted infections, mental health conditions) were observed in most groups, and decreases in some protective factors (eg, participation in the California Women, Infants, and Children program) (P for trend < .001 from 2011 to 2021) were observed mostly in low-income groups. Conclusions and Relevance:In this cohort study of singleton live births in California, PTB rates increased in many groups. Persistent racial and ethnic and socioeconomic inequities were also observed. Changes in risk and protective factors provided clues to patterns of PTB. These data point to an urgent need to address factors associated with PTB at both the individual and population levels.

© Author(s) (or their employer(s)) 2023. No commercial reuse. See rights and permissions. Published by BMJ. Equity is one of the six core healthcare quality domains in ‘Crossing the Quality Chasm’, published by the Institute of Medicine in 2001. While substantial quality measurement and improvement work has focused on improving safety, patientcentredness, timeliness, efficiency and efficacy (the other five domains), far less has focused on health equity measurement and improvement. This is in part due to limited adoption of standardised definitions of racial and ethnicities and therefore limited availability of highquality data on race and ethnicity. Having accurate data is a key first step in addressing health inequities, since what is measured influences what is done. There are substantial efforts to improve these data availability and quality by healthcare systems, nationally and internationally. Currently, adequate efforts require several steps: the decision to collect data, ensuring the quality of data being collected, and reconciliation of race and ethnicity data across frequently nonstandardised data collection systems. The study by Lyren and colleagues in this issue of BMJ Quality & Safety focuses on the third step, providing a replicable method to use race and ethnicity data while data standardisation efforts continue. Data collection and analytics are a core principle of advancing health equity, positioned within a larger framework to ultimately improve individual and populationlevel health.

OBJECTIVE:To evaluate structural racism in the neonatal intensive care unit (NICU) by determining if differences in adverse social events occur by racialized groups. STUDY DESIGN:Retrospective cohort study of 3290 infants hospitalized in a single center NICU between 2017 and 2019 in the Racial and Ethnic Justice in Outcomes in Neonatal Intensive Care (REJOICE) study. Demographics and adverse social events including infant urine toxicology screening, child protective services (CPS) referrals, behavioral contracts, and security emergency response calls were collected from electronic medical records. Logistic regression models were fit to test the association of race/ethnicity and adverse social events, adjusting for length of stay. Racial/ethnic groups were compared with a White referent group. RESULTS:There were 205 families (6.2%) that experienced an adverse social event. Black families were more likely to have experienced a CPS referral and a urine toxicology screen (OR, 3.6; 95% CI, 2.2-6.1 and OR, 2.2; 95% CI, 1.4-3.5). American Indian and Alaskan Native families were also more likely to experience CPS referrals and urine toxicology screens (OR, 15.8; 95% CI, 6.9-36.0 an OR, 7.6; 95% CI, 3.4-17.2). Black families were more likely to experience behavioral contracts and security emergency response calls. Latinx families had a similar risk of adverse events, and Asian families were less likely to experience adverse events. CONCLUSIONS:We found racial inequities in adverse social events in a single-center NICU. Investigation of generalizability is necessary to develop widespread strategies to address institutional and societal structural racism and to prevent adverse social events.

To the Editor: The first commentary piece we wrote was a call to eliminate race-based medicine in medical training materials. In it, we identified ourselves as women of color training in academic pediatrics. We were enthusiastic about the opportunity to submit an agent of change to a leading journal. The rejection letter provided appreciated constructive feedback from the reviewers and we readily accepted the decision. Unexpectedly, the editor additionally suggested we use a less “angry” tone and submit the commentary to a health-related social media platform instead. The following month JAMA released a disastrous, tone-deaf podcast on structural racism. After public criticism, the editor stepped down. 1 Leading scholars have recently described the paucity of published articles referencing racism and outlined a new standard for publishing on race inequities. 2,3 Unfortunately, editorial boards—both the gatekeepers and leading voices in medicine—tend to be a monolithic group lacking diversity. 4 Our experience was not only timely, but it provided additional motivation to the underlying spirit of our original work: To reveal the roots of the problematic incorporation of systemic racial inequities in medicine. Here, we call for: Long-term investment in the diversification of academic medical journal editorial boards; Transparency of editorial board and reviewer demographics; A system of anonymous peer review feedback in which authors can report racism and/or discrimination; and Active incorporation of underrepresented trainees in the review process. We hope these changes will lead to medical journals prioritizing publications that describe and provide solutions for health inequities and systematic racism, while also encouraging women of color to pursue careers in academia. We cannot underestimate the power of diversity and the pipeline of success it inherently creates. This week I received my first reviewer invitation for a major academic journal. Here’s to change. Acknowledgments: The authors thank Elizabeth E. Rogers, MD, and Matthew S. Pantell, MD, MS, for their guidance throughout this process.